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CIP Notice and Request Form

Thank you for opening your investment account with us. In addition to the other forms and information required in order to establish your account, recent changes in the law require that we provide all our new accounts with this notice concerning our compliance with certain anti-money laundering requirements applicable to all financial firms, according to our firm’s Customer Identification Program (“CIP”), established pursuant to applicable provisions of the USA PATRIOT Act of 2001.

This is to inform you that, pursuant to recent applicable statutory and/or regulatory requirement or guidance, supplemental customer identification information will be gathered to provide further assurance that customers opening accounts with or through National Securities Corp. have provided accurate and complete customer identification information. This is in an effort to preclude individuals or entities representing terrorist groups, drug cartels, criminal organizations, or their associates, or others known to have engaged in money-laundering activities in the past, from using this firm, or any of its associated persons, as an unwitting conduit for financing their activities. We appreciate your cooperation in helping us fulfill the goals of the USA PATRIOT Act.

IN THIS REGARD, PLEASE RETURN TO US COPIES OF AT LEAST ONE ITEM LISTED BELOW AND/OR ALL SUPPLEMENTAL INFORMATION REQUESTED FOR OUR FILES (IN ADDITION TO THE NEW ACCOUNT FORM AND ANY OTHER FORMS):

_____ Driver’s License

_____ Passport

_____ Birth Certificate

_____ Photo ID

_____ Background Documents

_____ Personal References

_____ Other _________________________________________________________

_____ Articles of Incorporation

_____ Partnership Agreement

_____ Trust Certificate

_____ Entity Documentation

_____ Governmental License/Permit

_____ Business References

IF YOU HAVE ANY QUESTIONS REGARDING THE FOREGOING, CONTACT YOUR REGISTERED REPRESENTATIVE.

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